Anesthesia

A comment from an anesthesiologist:
As a practicing anesthesiologist I can only reiterate that communicating with your doctors is key. I have yet to have a patient on Suboxone or their primary doctor contact me prior to surgery. I have had to cancel cases because nothing was done with the Suboxone dose prior to surgery. This is a simple fix as long as you communicate with your anesthesiologist ahead of time. I think a lot of this has to do with a lack of knowledge in the primary care arena about Suboxone.  Eric Swetland MD
Response:
Thanks Dr. Swetland for your comment.  As a former anesthesiologist I try to get patients to plan ahead and foster communication with me, the surgeon or OB, the anesthesiologist… but it still is often left for the morning of surgery.  One of my patients had a C-section a couple months ago– she told her OB to call me and I called once and left a message, but he did not call until the morning of her stat c-section, after the case was done and she was writhing in pain in the recovery room as her SPINAL wore off.  He asked what he should do, and I said ‘an epidural would have been nice….’.  I ended up recommending that they put her in the ICU and give her mega-doses of narcotics, and that is what they did.  She was fine, but an epidural would have allowed greater comfort and less expense.


Another patient had a vaginal delivery of a healthy baby;  the hospital, though, was not ‘comfortable’ with Suboxone and so a neonatologist was involved.  The patient begged him to call me–  I did not know at the time that this was going on– but he told her that ‘he knew what he was doing without calling some other doctor’ (oh, the ego!).  Against her wishes he put her baby on a morphine infusion to treat withdrawal;  the nurses were curt and rude, a couple making statements to assure she felt guilty about her baby’s ‘withdrawal’.  The nurses gave a number of conflicting statements about her wish to breastfeed her baby while taking Suboxone.  Afterward she told me that her baby looked like all the other babies before the morphine and after it was finally stopped– didn’t cry more, sleep less, etc… and I shared articles with her about the fact that newborns of Suboxone-using moms show minimal if any signs of withdrawal, and that breastfeeding is fine and results in no significant buprenorphine exposure for the infant.
I had a 67-y-o patient sent home from the ER after going in with a temp of 102 degrees F and sharp pains in the side of his chest– the doc told him ‘it was probably from the Suboxone’!!  I told him to go back, and I called the ER and told them it was NOT the Suboxone– they did x-rays this time and diagnosed his pneumonia!
Doctors have a bad habit of blaming symptoms on things they don’t know much about;  patients have their own problems by keeping their use of Suboxone to themselves, too embarassed to let their doctors know about their use.  I encourage everyone to communicate– this is a new drug and new paradigm, and it is important that everyone knows what they are dealing with.  OK… so much for the soapbox…
SD
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Suboxone and Epidural Anesthesia; pregnancy, delivery, and C-sections on Suboxone

I just saw a keyword from Albany NY: suboxone and epidural.  I presume this is a pregnant woman anticipating labor who is taking Suboxone.  I have had several patients deliver babies while on Suboxone;  two by C-section and one by vaginal delivery.  I also was an anesthesiologist for ten years before my opiate addiction took that away.  I miss it from time to time– it was a fun job.  The pace was perfect for my personality;  relax, relax, relax, TERROR, TERROR, relax, relax…  OK maybe it wasn’t good for me… but it was fun.  And I loved doing labor epidurals, as everyone loved me when I showed up– the women in labor, the OB nurses, the obstetrician (who could go back to bed)… even the husband, who could get some sleep as well (but only after the wife dozes off first).
As far as Suboxone, first understand that it is possible to do an epidural without using any opiate at all, and being on Suboxone doesn’t have to be a problem.  During labor for a vaginal delivery or during a C-section, either by general or by epidural (or spinal for that matter) the Suboxone is not a problem.  Yes, usually a very small amount of fentanyl is added to the infusion of and epidural and is given IV after the baby is born in a C-section.  But those steps are not critical.  In fact, my own wife hated epidural narcotics, as they always made her itch terribly, so she asked to keep them out for her last delivery.
I’ll talk about the things that are not a problem first.  It is not a problem to take Suboxone while breast feeding.  The only potential problem is that you will run into a militant breast feeding advocate who makes you feel guilty about the whole thing.  I did a literature search on the topic and found several papers for it, and one against it.  To summarize, a very small fraction of buprenorphine is excreted in breast milk;  the baby drinks the milk, and the suboxone quickly passes the mouth (skipping absorption there) and going to the stomach, duodenum, and liver.  The liver destroys almost all of the buprenorphine, as it does in adults.  For the sake of purity I do suggest using subutex at this point so that the baby is only exposed to one mosty harmless drug, instead of to two mostly harmless drugs.  In the papers I dug up there were no reports of babies becoming sedated or drugged after breast feeding from moms on Suboxone.
Now, the problems…  it can be difficult to get good pain control in a person who dosed Suboxone on the morning of surgery.  One of my patients had it all set, to stop three days in advance… but then she had an immediate section a couple hours after dosing with 8 mg (I DO tend to reduce the maintenance dose from 16 to 8 mg in people close to surgery for this very reason;  it is half as hard to get pain relief after one pill than after two.  I was called after the surgery was over and she was in the recovery room.  They had done a spinal… my first comment was that ‘an epidural would have been nice, as we could have run dilute local anesthetic through it post-op with dilute bupivicaine to treat her pain, and it would have worked well. Since they didn’t do an epidural we ended up transfering her to the ICU, where they could keep her on oxygen monitorin and dose her with huge doses of morphine– 20-30 mg at a time.  The better way would be to stop the buprenorphine three days in advance, or at LEAST cut down to a very low dose, say 2 mg per day, and nothing on the day of surgery.  Remember, agonists will ‘out-compete Suboxone at the receptor if you have enough  of it there.
Talk to your anesthesiologist before hand.  They can be hard to find, and they don’t take ownership of cases until the last minute, but try to find on and ask him or her to do your case.  Pick the one that talks opently to you, as some anesthesiologists can be odd ducks.  Don’t let the Suboxone thing get you all worked up, and keep your focus on the wonderful new member of the family.  And it really is wonderful.
This final part is the worst part.  You might be judged, and that would be a shame, but some nurse might peg you as the ‘addict mom whose baby is withdrawing’.  First, remember that ALL babies cry.  Second, remember that YOUR experience with withdrawal is nothing like the baby’s experience.  Withdrawal is not all that painful– it is suffereing that we don’t like, not pain per se.  Think about it– we feel guilty, sad, low, we feel jealous of people who are still using;  we feel mad at ourselves for not arranging things better.  The baby feels NONE OF THIS.  Not only that, your baby just squeezed through a tunnel so tight that they had to pull on his head to get him out of there.  He was gasping like mad, using fluid-filled lungs, trying to catch his breath.  So if he is crying too much, or not crying enough, or too hungry, or not hungry enough (you get the idea) give yourself a break and just ignore what people say.  Your baby is fine;  don’t treatment him like a medical specimen.  All of the data we have shows no problems with babies born to mothers on Suboxone.

Precipitated Withdrawal

thank you anyway for replying.. So when i do get into seeing a doctor, i must be in withdrawal? I am so confused on this issue.  I am taking suboxone, but most likely have to take the lortab when it is out of my system because of the pain i do have. The lortabs are a prescription that i have been on for over a year.  I just know that i can’t stop taking them on my own, thats why i tried the suboxone.  I researched how to take it and it works wonders for me.
My Answer:
The primary issue with precipitated withdrawal isn’t so much being in withdrawal, but instead has to do with your level of tolerance.  Tolerance goes up with every dose of an agonist, and plummets when a person is in withdrawal.  In predicting precipitated withdrawal one looks at whether a person’s tolerance is higher or lower than it would be taking 30 mg of methadone per day.  A person taking 100 mg of methadone per day who didn’t start withdrawal will have severe withdrawal during Suboxone induction;  A person taking 10 mg of methadone per day who didn’t start withdrawal may actually get a mild ‘high’ during methadone induction.  Lortab includes hydrocodone, the active ingredient in Vicodin.  Hydrocodone is metabolized to a more potent drug—hydromorphone or Dilaudid—to varying degrees in different people (I am about to post something about that), so it is hard to predict the tolerance level in a person on hydrocodone.  The tolerance depends on how their genetics make them metabolize the drug.  For that reason one cannot simply say that 50 mg of vicodin per day won’t result in precipitated withdrawal.  These metabolic relationships occur with other opiates as well and explain why some people say they have never had precipitated withdrawal, and other people do have it, despite taking the same doses of the same opiate.


It is impossible to guarantee that precipitated withdrawal won’t occur, but one can make it exceedingly unlikely by reducing their use of opiates a bit as the induction approaches and then getting good and miserable before starting the induction by discontinuing use for 24 hours or so.  People on super-high doses of a drug like methadone (which tends to stay around in the body for awhile) have the highest risk for precipitated withdrawal, but can make it unlikely by stopping use for 3-4 days, as tolerance drops the fastest in a person who completely stops using.  For what it’s worth, I had precipitated withdrawal myself back in my using days on at least 3 occasions;  twice, in desperation, I took oral naltrexone (an opiate blocker) thinking it would help me stop using;  a third time I injected IV narcan by accident.  The naltrexone incidents were the worst, as that drug lasts for 24 hours or so.  It was pretty horrible, but I did live through it, and the experiences certainly gave me a stronger desire to stay clean!
SD
Fond du Lac Psychiatry
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Suboxone and Anesthesia; Suboxone vs. 'Recovery'

Yes, I have changed blog platforms again… hopefully for the last time! I spent the past few days learning to use the self-hosted WordPress platform. After reading the instructions about uploading the program using FTP (no small task for non-techies like me) I went to my GoDaddy hosting account and found that by clicking a couple buttons it automatically installed for me. Since then I have discovered the different WordPress templates available, the widgets, the plug-ins… cool stuff!

But back to Suboxone. One of the questions on today’s keywords was ‘Suboxone vs. Recovery’– I won’t go into that at length now but will direct interested readers to my article at Subox.info, where I give some thought to the different things that happen to personality when an addict takes Suboxone vs when an addict goes through traditional step-based treatment. The article is on one of the last pages of that web site.
Another keyword question was ‘Suboxone and Anesthesia’.
As you may know I worked as an anesthesiologist for about ten years before my career was skewered by my opiate addiction.  I still miss the job, but it probably wasn’t good for me… I joke that my arms were getting sore from pushing around that wheelbarrow full of money!  It certainly paid very well, but more than that I loved the feeling of power and control that comes with supporting a patient during surgery, or from totally relieving the pain of a woman in labor.  Anesthesiologists are always heroes in the hospital.  Some patients don’t know just how important the anesthesiologist is, but the nurses and surgeons certainly do.  I felt like a cowboy, as I raced in from home to secure the airway of a 13-y-o boy who had hung himself and whose neck anatomy was swollen and distorted… or as I ran down the hall to the operating room just ahead of the stretcher carrying a woman whose uterus had ruptured as she labored with her tenth kid.  I still vividly remember standing in the middle of the road at about two AM, after we saved the mom and baveby in that case.  It was snowing, and the city was asleep and very quiet, and as I looked at the dark windows of the house down the street I thought that I was the luckiest man in the world to have such a job.  A few years later the job was gone, and my feelings of power were challenged every day as I came to terms with all of the changes in my life– I was doing physical exams for a fraction of my old salary, the weekly dinner parties came to a halt (in seven years I haven’t been invited to a single one of the houses that I used to go to on a monthly basis), two close friends were dead (one a surgeon who committed suicide and the other Commander Shanower killed at the Pentagon on 9/11), our vacation cottage that the family loved was sold to pay the bills…
I didn’t intend to go down this path.  These thoughts used to be very painful for me, but now I can reflect and almost smile.  I see people in my practice who are facing changes in their lives, and it is nice to know what the situation feels like so that I can understand them.  I can also say with complete certainty that one cannot predict what the future holds, particularly when one’s view is colored by depression or other psychiatric symptoms.  I can also say that if an addict stays clean and works a recovery program, good things will ALWAYS happen.
Anyone interested in my personal story by the way can watch for a book that I am writing called ‘Terminal Uniqueness’.  I am trying to decide if I should post it on Twitter as I go or just wait until I am done.
Suboxone does not interfere with MOST anesthetics.  An anesthesiologist has a number of choices of general anesthetics (regional anesthetics using local anesthetics injected into areas to make things numb are not affected by Suboxone either).  A couple examples– one can do a ‘gas-based’ anesthetic where inhaled agents cause amnesia and anesthesia, or one can do a ‘balanced anesthetic’ using combinations of opiates and other IV medications, perhaps with smaller amounts of a gaseous agent as well.  Suboxone WILL block the opiate portion of this anesthetic, but there are plenty of other agents to use to replace the opiates.
The main problem comes after the surgery in the recovery room, when Suboxone prevents morphine, demerol, and other medication from controlling the surgical pain.  One of my patients had an emergency C-Section shortly after dosing with Suboxone and it was difficult to get her pain under control.  Eventually she was transferred to the ICU for close monitoring as they gave her huge doses of morphine– which eventually controlled her pain.  Some surgeries will be of a nature where injections of local anesthetic can provide considerable pain relief for up to twelve hours.  This is a particularly good option for procedures on the extremities.  Sometimes an epidural can help a great deal with pain control after abdominal procedures, or even chest procedures.  In cases where opiates need to be used, the dose will usually need to be surprisingly high, at levels where nobody will be comfortable unless the patient is continually monitored for respiratory function in a step-up unit like the ICU.

I have helped six or seven Suboxone patients through the surgical process and for the most part they have done well.  Stopping Suboxone for three days prior to surgery will make pain control much easier after the surgery.  Even if sufficient time has elapsed to get rid of the Subxone, though, the person will still have a much higher tolerance than patients not on Suboxone, so I strongly recommend discussion the fact that you are on Suboxone with your surgeon and your anesthesiologist.  If you don’t, they won’t know what is going on, and won’t be able to take the proper steps to help you.
SD
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Emergency Pain Relief While On Suboxone

I took a look at my blog stats today, and one of the interesting things to review is the collection of keywords that people have used on their way to this site.  Some of the keywords consist of questions, and  I will try to answer the questions as time allows.  The following question appears several times on the list of keywords:
If on small dose of suboxone and need emergency pain relief is it dangerous?
The fast answer is no– it is not dangerous.  There is a common misconception among people using Suboxone that I hate to correct, as maybe it keeps people clean.  But on the other hand there will be times when Suboxone patients need pain relief– they are not immune from car accidents, skiing accidents, work injuries, etc– and they need to know the facts about the medication they are taking.
The confusion probably occurs because Suboxone will make a person sick– sometimes very sick– if it is taken while a person is still ‘high’ on opiate agonists (or on opiate agonists and not yet withdrawing from them).  Agonists, remember, are the drugs that activate a receptor;  opiate agonists include morphine, demerol, oxycodone, hydrocodone, etc.  At the molecular level buprenorphine, the active drug in Suboxone, binds tightly to the opiate receptor, blocking the area that agonists would otherwise bind to.  (actually it is a bit more complicated– you get into probability theory when you get down to what actually happens.  The molecule of buprenorphine ‘associates with’ and ‘dissociates from’ the receptor so rapidly that the binding can be characterized by the ‘probability’ that the receptor is bound vs not bound at any moment).  As the buprenorphine alternates between bound and unbound to the receptor, it is competing with any other opiate agonists, and winning the battle, as buprenorphine is a very good ‘fit’ at the receptor.  If a person is tolerant to opiates, he/she requires agonist binding at the receptor in order to maintain the normal neuron firing patttern and avoid withdrawal.  If buprenorphine is added at that point, it will out-compete the opiate agonist and ‘displace’ it, essentially making it less likely that the receptor will be occupied by the agonist at any moment in time.  This causes less activation of the receptor, the neuron stops firing, and a series of brain events occur that result in withdrawal.
The question is concerned with a different sequence of events;  a person is taking suboxone (which is therefore bound to the receptors) and suddenly needs pain relief, and takes an opiate agonist.  In a person not on Suboxone, the goal is to over-activate the receptor and make the neuron fire more than usual, so that it sends messages down the spinal cord that reduce the ability of pain signals to get through.  But if the receptor is blocked by Suboxone, the agonist is not going to work well.  In fact, if the buprenorphine dose is high enough, the agonist won’t have any effect at all… unless it is given in very high levels.  Remember that the drugs compete at the receptor, and buprenorphine is better at competing than most agonists;  if you give enough of the agonist, it will eventually overcome the block by buprenorphine.
So if a person taking Suboxone needs pain relief (or wants to get high), normal doses of opiate agonists will not have any effect.  They won’t make the person sick either.  I recommend that patients on Suboxone carry a card in their wallet that tells EMTs that they are on an opiate blocker, in case they are injured and are unable to talk.  That way, if the person is writhing in pain in the ER as a chest tube is being inserted, the docs will hopefully give much higher doses of morphine than usual to relieve the pain.
There are two reasons to limit the dose of Suboxone to the lower range in my opinion– one is to save money, and the other is so that if an emergency occurs, it is not impossible to attain pain relief.  I tend not to restrict the dose, by the way–  I find that a dose of 16 mg works best at eliminating cravings and provides the highest margin of safety from relapse.  But a person who has a higher than average chance of needing emergency surgery may want to consider taking a lower dose, so that the block is easier to overcome during emergencies.
I have had a few patients need emergency surgery while on Suboxone.  Most did OK–  I had one poor woman though who took her morning Suboxone and then needed an emergency C-Section.  I was called by the OB doc after the surgery, when the patient was in pain in the recovery room and the spinal was wearing off.  My first thought was that if they had called before the surgery, I could have told them to place an epidural– they could then run in a dilute mixture of local anesthetic and totally relieved her pain.  But they did a spinal, so that was out (it is hard to go back and do an epidural after a spinal– positioning the patient, etc, but also, the hole in the dura mater from the spinal can make an epidural more erratic and potentially dangerous).  Other options included IV toradol, an aspirin-type medication, as long as bleeding wasn’t a problem. This patient still had severe pain though, so using the principle of competition at the receptor, I recommended that they move the decimal in their dosing of morphine and just give what it takes.  She went to the ICU for monitoring and they gave her BIG doses of morphine– 20, 30, 50 mg at a time.  Everyone was nervous, but it worked.  (the concern is respiratory depression–  that is why she went to the ICU, as the floor nurses were appropriately too nervous to give those kind of doses without being able to watch respiratory rate closely).  The only problem with such high doses of morphine is that IV morphine can cause release of histamine in the bloodstream– the nasty chemical that makes you sneeze, itch, and swell during allergies.  After a couple doses the available histamine is ‘used up’ and not a problem, but the first dose or two should be smaller, and then gradually increase, in order to prevent a massive histamine reaction.  Some benadryl is helpful as well.
A couple final comments:  Do NOT engage in trying to ‘out-compete’ your own receptors using opiate agonists, while taking Suboxone.  Doing so is very dangerous, as you can go from a non-competing dose to an out-competing dose without realizing it until too late– and the result would be a fatal overdose from respiratory arrest.  Respiratory monitoring is necessary whenever this type of thing is going on!!!!  The other thing is that while the principle of competition is straightforward, do not be surprised if you doctor refuses to go along.  Most doctors are freaked out by giving such high doses of narcotics.  I was an anesthesiologist for 10 years, so for me it is not a big deal… but most surgeons, unfortunately, are more comfortable with a moaning patient than with writing for real high doses of morphine.  ALWAYS plan ahead for surgery if at all possible– talk to the anesthesiologist, the surgeon, and anyone else who will be involved in your care.  Have a plan in place to deal with the pain.
If the surgery is planned I recommend stopping the Suboxone at least 3 days before the surgery so that it gets to a low level in your system by the day of surgery.  It takes a LONG time to clear buprenorphine!  And let your surgeon know that you are taking an opiate blocker, and that your tolerance is artificially much higher than normal.  Again, I hate to generalize in a negative way but some doctors, when told of a high tolerance and need for higher doses, respond by being more stingy with the dosing!!  (you know–  BAD addict! BAD!  BAD!!).  The dose of every medication has limits, but people addicted to opioid have the same right to reasonable analgesia as other patients.

Long-Term Effects of Suboxone

A note from a reader with a question about Suboxone:

Suboxone has really worked for me in getting off vicodin.But I have been unable to stop taking Suboxone.It occurred to me recently that this may turn into a lifelong dependency.If so, what are the long-term side effects of Suboxone?

Thanks so much,

My Answer:
Suboxone really is best thought of as a long-term, perhaps life-long medication.Your attachment to pain pills will in all likelihood be life-long as well; most people who stop Suboxone are surprised at the cravings for opiates that they have.I don’t think Suboxone increases the cravings at all, but rather it is just so effective at eliminating them that people forget how attached to opiates they once were.I generally recommend that people stay on Suboxone ‘forever’, or until something better comes around– they are much safer on Suboxone, as it helps them avoid an impulsive relapse that can put them in jail, kill them, etc…
We do not know of many long term effects from Suboxone.Long term opiate use in general can lower testosterone levels in men and cause things from that, like reduced sex drive and I suppose even infertility.I assume that buprenorphine will do the same.There are the other short-term side effects that over time become long-term side effects– dry mouth (which long-term can cause an increase in tooth decay), constipation (which could lead to hemorrhoids, diverticulitis, anal fissures or peri-rectal abscess), sweating (which could lead to… problems dating?). The opiate antagonist naltrexone can cause liver damage, and it is related to naloxone, which is a component of Suboxone– in general the naloxone does not get absorbed, and so the chance of liver damage is likely minimal.It may be a good idea to check a set of labs once per year, though, to check the liver, kidneys, thyroid, and blood cell system, just for safety’s sake.
Probably the worst thing about long-term use is that some docs insist upon keeping everyone on Suboxone in endless therapy.I do not think that therapy is generally required, and I do not think that ‘forced therapy’ is very helpful.But it is hard to find a doc who will treat with Suboxone as they would treat with any other treatment for a chronic condition– that is, to prescribe the medication without placing a number of other requirements on the person.
I hope that answers your questions–
Take care,
J